Information Collection

Partner Survey

IC 226367 under ICR 202105-0938-002 · OMB 0938-1342.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1342 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10632 Partner Survey	Form and Instruction
CMS-10632 Appendix A - Partner Survey: Informed Consent and Survey CMS-10632.Appendix_A_Partner_Survey_srs_022221.pdf	Form and Instruction
CMS-10632.Appendix_C_Recruitment_Script_srs_022221.pdf Recruitment script	IC Document
CMS-10632.Appendix_D_Support_Letter_from_CMS_OMH_srs_012221LM.pdf Letter of Support	IC Document

IC Title:

Partner Survey

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10632	Appendix A - Partner Survey: Informed Consent and Survey	CMS-10632.Appendix_A_Partner_Survey_srs_022221.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 60

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	60	60
Annual IC Time Burden (Hours)	20	20
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Recruitment script	CMS-10632.Appendix_C_Recruitment_Script_srs_022221.pdf	05/06/2021
Letter of Support	CMS-10632.Appendix_D_Support_Letter_from_CMS_OMH_srs_012221LM.pdf	05/06/2021

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.